Design and Validation of a Prehospital Stroke Scale to

Predict Large Arterial Occlusion

The Rapid Arterial Occlusion Evaluation Scale
Natalia Prez de la Ossa, MD, PhD; David Carrera, MD; Montse Gorchs, BD;
Marisol Querol, BD; Mnica Milln, MD, PhD; Meritxell Gomis, MD, PhD;
Laura Dorado, MD, PhD; Elena Lpez-Cancio, MD, PhD; Mara Hernndez-Prez, MD;
Vicente Chicharro, MD; Xavier Escalada, MD; Xavier Jimnez, MD, PhD; Antoni Dvalos, MD, PhD
Background and PurposeWe aimed to develop and validate a simple prehospital stroke scale to predict the presence of
large vessel occlusion (LVO) in patients with acute stroke.
MethodsThe Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health
Stroke Scale (NIHSS) items with a higher predictive value of LVO on a retrospective cohort of 654 patients with acute
ischemic stroke: facial palsy (scored 02), arm motor function (02), leg motor function (02), gaze (01), and aphasia
or agnosia (02). Thereafter, the RACE scale was validated prospectively in the field by trained medical emergency
technicians in 357 consecutive patients transferred by Emergency Medical Services to our Comprehensive Stroke
Center. Neurologists evaluated stroke severity at admission and LVO was diagnosed by transcranial duplex, computed
tomography, or MR angiography. Receiver operating curve, sensitivity, specificity, and global accuracy of the RACE
scale were analyzed to evaluate its predictive value for LVO.
ResultsIn the prospective cohort, the RACE scale showed a strong correlation with NIHSS (r=0.76; P<0.001). LVO was
detected in 76 of 357 patients (21%). Receiver operating curves showed a similar capacity to predict LVO of the RACE
scale compared with the NIHSS (area under the curve 0.82 and 0.85, respectively). A RACE scale 5 had sensitivity 0.85,
specificity 0.68, positive predictive value 0.42, and negative predictive value 0.94 for detecting LVO.
ConclusionsThe RACE scale is a simple tool that can accurately assess stroke severity and identify patients with acute
stroke with large artery occlusion at prehospital setting by medical emergency technicians.(Stroke. 2014;45:87-91.)
Key Words: cerebrovascular occlusion prehospital emergency care scales stroke, acute

harmacological treatment of acute ischemic stroke is limited

to the administration of intravenous tissue-type plasminogen activator within the first 4.5 hours from symptoms onset.
Intravenous thrombolysis can be administered in Primary Stroke
Centers or Community Hospitals.1 Beyond intravenous treatment, endovascular approach is an evolving therapeutic option in
patients with large vessel occlusion (LVO) because it may offer
longer time window and higher rate of complete revascularization.2 Although some recent studies have failed to demonstrate
clinical benefit of endovascular treatment, data suggest that efforts
to shorten the delay from symptoms onset to endovascular treatment in Comprehensive Stroke Centres (CSCs) are necessary to
demonstrate the effectiveness of this therapy.35 Consequently, a
simple and accurate scale for paramedics may be a useful tool to
identify patients with LVO and allow their rapid transfer to a CSC.

Several prehospital stroke scales have been designed and

validated to identify patients experiencing an acute stroke.610
Moreover, few scales have been developed to assess stroke severity at the prehospital setting.11,12 However, these scales do not offer
information about the presence of LVO. The National Institutes
of Health Stroke Scale (NIHSS) may be useful to identify patients
with LVO but the best cutoff point is still controversial and this
scale is probably too time consuming and too complex to be used
by paramedics.1315 Recently, 2 simple scales have been reported
to identify patients with LVO but their validation by prehospital
personnel has not been performed as far as we know.16,17
The objective of this study was to evaluate the predictive value
of the Rapid Arterial oCclusion Evaluation (RACE) scale on the
detection of patients with acute stroke and LVO when used by
medical emergency technicians during the prehospital phase.

Received August 1, 2013; accepted October 17, 2013.

From the Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias I Pujol, Universitat Autnoma de Barcelona (UAB), Badalona,
Barcelona, Spain (N.P.d.l.O., D.C., M.M., M.G., L.D., E.L.-C., M.H.-P., A.D.); Sistema dEmergncies Mdiques (SEM) de Catalunya, Spain (M.G., M.Q.,
X.E., X.J.); and Grup Ambulncies La Pau, Badalona, Barcelona, Spain (V.C.).
Presented in part in abstract form at the European Stroke Conference in London 2013.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
113.003071/-/DC1.
Correspondence to Natalia Prez de la Ossa Herrero, MD, PhD, Stroke Unit, Neuroscience Department, Hospital Universitar Germans Trias i Pujol,
Carretera Canyet s/n, 08916 Badalona, Barcelona, Spain. E-mail natperezossa@gmail.com
2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org

DOI: 10.1161/STROKEAHA.113.003071

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by guest on December 22, 2015
87

88StrokeJanuary 2014

Methods

Table 1. RACE Scale

RACE Scale Design and Retrospective Validation

The items of the NIHSS with the highest predictive value of LVO were
identified on a retrospective cohort of 654 patients with a cerebral infarction of the anterior circulation admitted at the acute stroke unit of
our CSC from January 2006 to March 2010. LVO was diagnosed by
transcranial duplex accordingly with thrombolysis in brain ischemia
criteria18 and considered when a thrombolysis in brain ischemia 0 to
2 pattern was observed at the middle cerebral artery at 45 to 55 mm
depth. LVO was observed in 178 of 654 patients (27%). First, those
items of the NIHSS with the highest association with LVO were identified in a 2 test. Then, the predictive value of different combinations
of these items was determined by receiver operating curve analysis.
Some items were excluded to avoid difficulties and inconsistencies
in the assessment by paramedic personnel although they had a high
correlation with LVO (visual field and sensory, for instance). A high
global accuracy was obtained with the combination of 5 items that
finally built the RACE scale: facial palsy, arm motor function, leg
motor function, gaze, and aphasia or agnosia, graded as detailed in
Table1. Each item was scored using a simpler grading system than
the NIHSS, as detailed in Table 1 and Table I in the online-only Data
Supplement.

Validation of RACE on a Prospective

Prehospital Cohort
To the prospective validation, the RACE scale was included on the
usual Stroke Code (SC) protocol. SC system has been working in our
area for the past 8 years and it is activated by Emergency Medical
Services (EMS) or community hospitals in front of any patient with
clinical suspicion of an acute stroke within 6 hours from symptoms
onset. More than 60% of patients with acute stroke arrive at our hospital transferred by basic or advance vital care ambulances.19,20
Between February 2011 and March 2013, patients with acute stroke
or stroke mimics in whom SC was activated from a community hospital or directly by EMS who were transferred by basic vital care ambulances to our CSC were considered for the prospective validation.
The RACE was completed in the field by emergency medical technicians, written on a sheet form before hospital arrival and given to the
neurologist at the hospital. Medical emergency technicians operating
into our geographical area received a training program at the beginning of the study. The program consisted of 1-hour training session
on the use of the RACE scale plus 4 shorter sessions during the first
year to solve doubts and to ensure good compliance of the protocol.
Moreover, when possible, the scale was discussed with the neurologist
at the CSC for each individual case after its completion by medical
emergency technicians.
Baseline characteristics, stroke subtype, and revascularization
treatment were recorded prospectively. The presence of LVO was
documented on admission using transcranial duplex (thrombolysis
in brain ischemia grades, 02) as a screening tool in most of the
patients and using computed tomography angiography or MR angiography in patients with suspicion of LVO. Angiography was
performed when endovascular treatment was finally indicated. LVO
was defined as occlusion of the terminal intracranial carotid artery,
proximal middle cerebral artery (M1 segment), tandem (extracranial
carotid artery plus middle cerebral artery) and basilar artery. The
study protocol was approved by the institutional Ethics Committee
of the Hospital Universitari Germans Trias i Pujol.

Statistical Analysis
For statistical analysis, SPSS version 15.0 software was used. Receiver
operating curves and areas under receiver operating curve (c-statistics)
were calculated as a measure of predictive ability for LVO of the RACE
and NIHSS scales. Ideal prediction produces a c-statistic of 1.00; precision no better than chance is associated with c-statistic of 0.50.
Correlation between both scales was analyzed with the nonparametric Spearman coefficient. Cross tables for different cutoff values of
the RACE scale were used to evaluate sensitivity, specificity, positive

Item

RACE Score

NIHSS Score
Equivalence

Facial palsy
Absent
Mild

Moderate to severe

23

01

Arm motor function

Normal to mild
Moderate

Severe

34

01

Leg motor function

Normal to mild
Moderate

Severe

34

Absent

Present

12

Head and gaze deviation

Aphasia* (if right hemiparesis)

Performs both tasks correctly

Performs 1 task correctly

Performs neither tasks

Patient recognizes his/her arm

and the impairment

Does not recognized his/her arm

or the impairment

Does not recognize his/her arm

nor the impairment

Agnosia (if left hemiparesis)

Score total

09

NIHSS, National Institutes of Health Stroke Scale; and RACE, Rapid Arterial
oCclusion Evaluation.
*Aphasia: Ask the patient to (1) close your eyes; (2) make a fist and
evaluate if the patient obeys.
Agnosia: Ask the patient: (1) while showing him/her the paretic arm: Whose
arm is this and evaluate if the patient recognizes his own arm. (2) Can you
lift both arms and clap and evaluate if the patient recognizes his functional
impairment.

predictive value, negative predictive values, and overall accuracy for

the presence of VO.

Results
In the retrospective cohort of 654 patients the RACE scale was
calculated based on NIHSS at admission (Table 1) and showed
a similar predictive value compared with the NIHSS for detecting LVO (area under the curve, 0.81 versus 0.80). Correlation
between RACE and NIHSS scores was 0.93 (P<0.001).
In the second phase the RACE scale was assessed prospectively by medical emergency technicians in the field
in patients transferred to our CSC via SC activation in a
24-month period. Of the 1184 patients admitted to our center
via SC in this period, we excluded 231 patients who arrived by
private transport directly at the emergency department and 68
patients who had an in-hospital stroke. These cases were not
attended and transferred by ambulance so the RACE scale was

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Perez de la Ossa et al Prehospital RACE Scale and Large Arterial Occlusion 89

not evaluated. Thus, 885 patients with extrahospital SC activation were studied. The RACE scale was completed in 357
of 885 patients (40%): 291 of 536 (54%) transferred directly
from home or public location by EMS, 34 of 278 (12%) transferred from community hospitals, and 32 of 71 (45%) transferred from primary care centers. Patients with RACE scale
assessment were similar to those in whom the scale was not
evaluated (n=528/885) although clinical severity was higher
(Table II in the online-only Data Supplement).
Finally, a total of 357 patients with a prehospital RACE
scale evaluation were included for the analysis (54% men;
meanSD age, 7313 years; median [quartiles] NIHSS score,
8 [316]). Time from symptoms onset was unknown or during
sleep in 104 of 357 (29%) patients. In the rest of the cases,
mean time from symptoms onset to EMS attention was 40
(24104) minutes and to neurological attention at the CSC
was 95 (63180) minutes. The stroke subtype was ischemic
stroke in 240 of 357 (67.2%), hemorrhagic stroke in 52 of 357
(14.6%), transient ischemic attack in 20 of 357 (5.6%), and
stroke mimic in 45 of 357 (12.6%).
A strong correlation was observed between the RACE scale
assessed by medical emergency technicians before hospital
arrival and the NIHSS assessed by neurologist at admission
(r=0.76; P<0.001).
LVO was detected in 76 of 357 (21.3%) patients. Diagnostic
methodology and site of occlusion are detailed in Table2.
Receiver operating curves demonstrated that the RACE
scale was highly effective in identifying patients with LVO
(c-statistic, 0.82; 95% CI, 0.770.87). Cutoff values of the
RACE scale for predicting LVO were evaluated (Figure1;
Table3). The best predictive value of RACE was established
as 5; this cutoff value showed sensitivity 0.85, specificity
0.68, positive predictive value 0.42, and negative predictive
value 0.94 for detecting LVO. In the subgroup of patients with
a final diagnosis of ischemic stroke of the anterior circulation
(n=214), the global accuracy of the RACE scale for LVO was
slightly higher (c-statistic, 0.84; 95% CI, 0.790.89).
The higher the RACE score, the higher the proportion of
patients with ischemic stroke because of LVO and the lower
the proportion of patients with ischemic stroke without
LVO or stroke mimics. Proportion of hemorrhagic stroke in
patients with high scores on the scale was also high (Figure2).

Table 2. Diagnostic Method for LVO and Site of Occlusion

No occlusion
MCA M1

Transcranial
Color Doppler
(n=197)

Angio-TC or
Angio-RM
(n=53)

Arteriography
(n=28)

Site of
Occlusion,
Total (n=278)

159

36

202

Figure 1. Sensitivity (squares) and specificity (circles) of different

cutoff values of the Rapid Arterial oCclusion Evaluation (RACE)
scale for the detection of large vessel occlusion.

Importantly, 29 of 154 (19%) patients with a RACE 5

received endovascular treatment compared with 4 of 203 (2%)
of those with RACE scale <5 (P<0.001).
RACE scale was comparable with NIHSS to predict LVO
(c-statistic, 0.85; 95% CI, 0.810.89). Best overall accuracy
for the NIHSS scale was achieved for a score of 11, with a
sensitivity 0.88, specificity 0.72, and overall accuracy 0.76.

Discussion
This study demonstrates that the RACE scale is a simple tool
highly predictive of the presence of a large arterial occlusion in
patients with a suspicion of an acute stroke. Moreover, we have
shown that its use at the prehospital setting is feasible as the
accuracy of the RACE scale evaluated by medical emergency
technicians is comparable with the NIHSS assessed by neurologist at hospital admission. The RACE scale shows a high
sensitivity (85%) and specificity (65%) to identify LVO when
considering a cutoff point of 5, or even higher sensitivity (89%)
with lower specificity (55%) with a lower cutoff point of 4.
This scale is the first validated tool to detect patients with
acute stroke and LVO at prehospital setting. Only 2 scales have
Table 3. Sensitivity, Specificity, PPV, NPV, and Overall
Accuracy of Different Cutoff Values of the RACE Scale for the
Detection of Large Artery Occlusion
RACE Score

No.

Sensitivity

Specificity

PPV

NPV

Accuracy

320

1.00

0.13

0.24

1.00

0.31

278

0.97

0.27

0.27

0.97

0.42

29

11

49

239

0.93

0.40

0.30

0.96

0.51

TICA

14

194

0.89

0.55

0.35

0.95

0.62

Tandem

12

154

0.85

0.68

0.42

0.94

0.72

Basilar

120

0.72

0.77

0.46

0.91

0.76

A total of 77 of 357 patients were not evaluated for LVO because they
experienced a hemorrhagic stroke (n=50) or a stroke mimic with no diagnostic
doubt (n=27). These patients were considered as having no occlusion for
theanalysis. LVO indicates large vessel occlusion; MCA, middle cerebral artery;
RACE, Rapid Arterial oCclusion Evaluation; and TICA, terminal intracranial
carotid artery.

71

0.53

0.89

0.56

0.87

0.81

37

0.32

0.95

0.65

0.84

0.82

0.07

0.99

0.56

0.79

0.79

NPV indicates negative predictive value; PPV, positive predictive value; and
RACE, Rapid Arterial oCclusion Evaluation.

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90StrokeJanuary 2014

Figure 2. Proportion of patients with ischemic stroke with large vessel occlusion
(LVO; black), ischemic stroke without LVO
(gray), hemorrhagic stroke (dashed), or
stroke mimic (white) for every Rapid Arterial
oCclusion Evaluation (RACE) scale score.

been designed to identify patients with LVO but they have not
been validated in the field. The 3-Item Stroke Scale assesses
level of consciousness, gaze, and motor function.16 However,
these items were not selected based on a comprehensive
analysis of the predictive value of the NIHSS items. The Los
Angeles Motor Scale is based on the motor items of a previous stroke identification instrument, which includes the facial
droop, arm drift, and grip strength.17 However, cortical signs
that are usually impaired in stroke with LVO are not evaluated.
Finally, the NIHSS is the only scale that has demonstrated to
be predictive of LVO, but prehospital assessment by medical
emergency technicians may be difficult, time-consuming, and
has not been validated as far as we know.1315 Although shorter
and simplified NIHSS have been designed and validated,21,22
no studies have analyzed its capacity to identify patients with
acute stroke and LVO.
The RACE scale may be a valuable tool for prehospital care
systems to detect and transfer acute stroke patients with a high
likelihood of experiencing a large arterial occlusion to a CSC.
SC systems have been developed worldwide to ensure specialized medical attention and early intravenous thrombolytic
therapy for patients with acute stroke. However, a new era
for stroke treatment is evolving because endovascular revascularization therapies are spreading worldwide.2 Indeed, in
patients with contraindications or who do not respond to intravenous treatment, an endovascular approach can be offered
to achieve more effective arterial recanalization. However,
clinical benefit of endovascular therapies is still being investigated. Delay to CSC arrival and low rate of early arterial
recanalization of patients treated with endovascular therapy
may be one of the principal causes of the failure of latest clinical studies.35 Indeed, some studies have demonstrated that the
earlier the arterial recanalization, the higher the clinical benefit of revascularization therapies.23,24 Therefore, early triage
of patients for endovascular treatment may have an important
clinical impact. Our results demonstrate that the use of the
RACE scale at a prehospital scenario is feasible by trained
medical emergency technicians and might be a useful and
simple tool to identify patients with LVO. Considering a cutoff value of RACE 5, medical emergency technician would

identify 85% of patients with LVO. In our series, 35% of these

patients received systemic thrombolysis and 19% were finally
treated with endovascular therapy. Direct transfer to a CSC
may imply a significant number of patients bypassing Primary
Stroke Centers potentially delaying intravenous tissue-type
plasminogen activator and not being eligible for endovascular
therapy. Thus, we suggest to investigate this new scale initially
as a triage tool in areas where Primary Stroke Centers are not
far from a CSC. We need stronger evidence about the efficacy
of endovascular treatment to extend the use of the scale into
a broader region. On the other hand, our results show a moderate specificity and positive predictive value of the RACE
scale, mostly because of the inclusion of patients with hemorrhagic stroke with severe symptoms and high scores on the
RACE and also the NIHSS scale. In our opinion this fact does
not hamper the usefulness of the scale because these patients
benefit from admission into a CSC where they may receive
neurosurgical evacuation, external ventricular derivation, or
hemicraniectomy. Future investigation of serum biomarkers
aimed to differentiate ischemic and hemorrhagic stroke may
complement this clinical tool at the prehospital setting.
This study has some limitations. First, the RACE scale was
not evaluated in 60% of patients transferred by EMS. Patients
not included had less severe strokes and less frequency of LVO
than patients included in the analysis (Table II in the onlineonly Data Supplement). Most of them were transferred from
community hospitals (as a secondary transfer made by EMS in
where the scale was not evaluated). Thus, we cannot rule out
a selection bias, and a larger validation study may be necessary to generalize our results. Second, LVO was diagnosed
using transcranial duplex in half of the patients, which may be
less accurate than computed tomography angiography or MR
angiography. However, previous studies have demonstrated
a high sensitivity (0.82) and specificity (0.94) of transcranial
Doppler in diagnosing LVO.25 Third, the RACE scale was
designed based on data from patients with anterior circulation
acute ischemic stroke, but the prospective validation study
also included few patients with posterior circulation ischemic
stroke (7%) and brain hemorrhage (14.6%). Although accuracy for detecting LVO was higher for the subset of patients

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Perez de la Ossa et al Prehospital RACE Scale and Large Arterial Occlusion 91

with anterior circulation ischemic stroke, results were also
good when analyzing the whole sample. Finally, during the
study period, ambulance dispatchers were trained regularly on
the RACE evaluation so we cannot conclude on maintained
accuracy of the scale over time in nontrained dispatchers.
As a strength of this study, one of the known limitations of
the NIHSS is improved by the RACE scale: left hemispheric
strokes tend to score more than those on the right because 7
of the items of the NIHSS are directly related to language,
whereas only 2 are directly related to agnosia.26 In the RACE
scale both items score a maximum of 2 points. However, right
hemisphere symptoms may be more difficult to assess by
medical emergency technicians because predictive value was
lower than for left hemisphere strokes.
In conclusion, the RACE scale is a novel and simple tool for
a prehospital use by medical emergency technicians that can
accurately assess stroke severity and detect patients with acute
stroke with large intracranial vessel occlusion. This tool may
be useful to early detection of patients with acute stroke who
should be transferred to a CSC for endovascular treatment.

Disclosures
None.

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SUPPLEMENTAL MATERIAL

Table I. RACE scale: items and NIHSS score equivalence

Item

Instruction

Facial palsy

Ask the patient to show teeth

Arm motor function

Extending the arm of the patient

90 degrees (if sitting) or 45
degrees (if supine)

Leg motor function

Head and gaze deviation

Extending the leg of the patient

30 degrees (in supine)

Observe eyes and cephalic

deviation to one side

Aphasia
(if right hemiparesis)

Ask the patient two verbal orders

- close your eyes
- make a fist

Agnosia
(if left hemiparesis)

Asking:
- Who is this arm while
showing him/her the paretic arm
(asomatognosia)
- Can you move well this arm?
(anosognosia)

RACE Score total

RACE score
Absent (symmetrical movement)
Mild (slightly asymmetrical)
Moderate to severe (completely
asymmetrical)
Normal to mild (limb upheld more than
10 seconds)
Moderate (limb upheld less than 10
seconds)
Severe (patient do not rise the arm
against gravity)
Normal to mild (limb upheld more than
5 seconds)
Moderate (limb upheld less than 5
seconds)
Severe (patient do not rise the leg
against gravity)
Absent (eye movements to both sides
were possible and no cephalic deviation
was observed)
Present (eyes and cephalic deviation to
one side was observed)
Normal (performs both tasks correctly)
Moderate (performs one task correctly)
Severe (performs neither tasks)
Normal (no asomatognosia nor
anosognosia)
Moderate (asomatognosia or
anosognosia)
Severe (both of them)

0
1
2

NIHSS score
equivalence
0
1
2-3

0-1

3-4

0-1

3-4

1-2

0
1
2
0

0
1
2
0

0-9

Supplemental Table II.

Comparison of patients transferred by EMS in whom the RACE scale was complimented (included n the study, n=357) or not complimented (not
included, n=528).

Included

Not included

n=357

n=528

Age, years

73 13

69 13

0.34

Gender (man)

54.1%

54.0%

0.98

NIHSS at
admission

8 [3-16]

5 [2-15]

0.006

LVO (%)

21%

14%

0.004

p value

Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion:
The Rapid Arterial Occlusion Evaluation Scale
Natalia Prez de la Ossa, David Carrera, Montse Gorchs, Marisol Querol, Mnica Milln,
Meritxell Gomis, Laura Dorado, Elena Lpez-Cancio, Mara Hernndez-Prez, Vicente
Chicharro, Xavier Escalada, Xavier Jimnez and Antoni Dvalos
Stroke. 2014;45:87-91; originally published online November 26, 2013;
doi: 10.1161/STROKEAHA.113.003071
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2013 American Heart Association, Inc. All rights reserved.
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